Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00245225 Renewal 06/11/2024 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The most recent self-assessment completed on 10/20/23 identified the following violations: 181f and 213(4). No plans of correction were developed for the violations.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Associate Directors of Operations shall gather all of the necessary supporting documentation of the corrective action plans by 7/12/24. 06/13/2024 Implemented
SIN-00226500 Renewal 07/05/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(a)The self-assessment for the home completed on 10/20/22 did not assess compliance with 6400.52a3.The agency shall complete a self-assessment of each home the agency operates serving eight or fewer individuals, within 3 to 6 months prior to the expiration date of the agency¿s certificate of compliance, to measure and record compliance with this chapter. Associate Directors of Operations and the Director of Operations shall standardize the annual self-assessment process, including assigning point people to ensure that all self-assessment items are marked appropriately. 10/01/2023 Implemented
6400.15(c)(Repeated Violation -- 7/11/22) The self-assessment for the home completed on 10/20/22 did not include a written summary of corrections for 6400.51b5.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations and Associate Directors of Operations will model after RCG guide to follow the five steps and instruct point people to write an effective Plan of Correction and focus on prevention of citations by 9/1/23. 10/01/2023 Implemented
SIN-00227593 Unannounced Monitoring 05/26/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.16Individual #1 receives residential services from Friendship Community. According to the current ISP, Individual #1 does best when they are given options for coping with their feelings and problems. Individual #1 often prefers creative outlets, such as drawing. On 4/25/23, Individual #1 told "Staff #2 and Staff #10 that a man hit them and was mad at them." Individual #1 also stated "He hit me. He works here. He was mad." On that date, Individual #1 picked out a picture of Staff #1. On 4/25/23, Staff #2 asked Individual #2 if they heard anything the night before. Individual #2 answered "Individual #1 was sad and yelling last night. They were crying." That entire week Individual #1 was fixated on the weather, particularly thunderstorms. Individual #1 would immediately say, "the man, he hit me, he was mad." On 5/5/23, Individual #1 drew a picture of what appeared to be a penis. On 5/5/23, during an interview between Staff #10 and Individual #1, the individual reported that Staff #1 grabbed their hand. They also showed on a picture that Staff #1 grabbed their knee and upper thigh. Individual #1 stated that Staff #1 was mad at them. Individual #1 stated that they feared Staff #1. Individual #1 confirmed a second time during that interview that Staff #1 grabbed their hand, knee, and upper thigh. Individual #1 picked Staff #1's photo as the person who they were referring to. Individual #1 was again asked to report what happened. Individual #1 pointed to the picture of the penis on the body chart. Individual #1 again confirmed that Staff #1 grabbed their hand. Individual #1 was asked if they had ever seen what was in the picture they had drawn. Individual #1 said, "Yes, a man." Staff #10 then asked, "Was it any of the men I showed you?" Individual #1 pointed to Staff #1's photo and said "He grabbed me on the hand. He grabbed my underwear. He pushed me on the bed. Scared." Individual #1 was asked "Did they touch you?" Individual #1 pointed to their own chest. Individual #1 was asked "Did you touch that on your body?" Individual #1 pointed to the picture they drew and said, "yes, I want to go home." During an interview between Individual #2 and the Certified Investigator on 5/8/23, Individual #2 stated that they hear Individual #1 crying in their room. "It's dark out." Due to the consistency with which Individual #1 has reported what occurred, it is determined that at the very least physical abuse occurred. In addition, there was sexual contact of some level between Individual #1 and Staff #1.Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals.Certified Investigation was started timely, law enforcement and Adult Protective Services was notified. Staff #1 was terminated. 08/15/2023 Implemented
6400.141(c)(8)Individual #1 has not had a mammogram. There is not an acceptable deferment letter on file.The physical examination shall include: A mammogram for women at least every 2 years for women 40 through 49 years of age and at least every year for women 50 years of age or older. Fax was sent to Individual #1 PCP to verify the proper need for a mammogram examination. Staff will ensure that either an acceptable deferment letter is received by 9/3/23 or that the mammogram for Individual #1 is scheduled by 9/3/23. 10/01/2023 Implemented
6400.144Individual #1 is to have one full bottle of Glucerna daily and an additional half a bottle with meals if they are eating less than a full meal, not to exceed two bottles a day. Based on the documentation provided it is impossible to discern how many bottles of Glucerna were given on 12/7/22, 12/18/22, and from 12/23/22-12/26/22. If Individual #1's blood sugar is over 200, they are not to receive any Glucerna that day. On 12/31/22, Individual #1's blood sugar tested at 319. The individual was still given their daily Glucerna. On 4/8/23, Individual #1's blood sugar tested at 189. Individual #1 was to receive a half a bottle of Glucerna on that date. They were not given any Glucerna.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. The Residential Coordinator will train the team on how to administer AB's Glucerna by: 8/18/23. 08/04/2023 Implemented
6400.52(c)(6)Staff #1 was not trained on Individual #1's glucometer or on how to complete finger sticks. The following staff who work with Individual #1 were not trained on Individual #1's ISP: Staff #2- Staff #6. The following staff who work with Individual #1 were not trained on Individual #1's ISP: Staff #1- Staff #9. The following staff who work with Individual #1 were not trained on Individual #1's Hyperglycemia Protocol: Staff #1, Staff #3-Staff #9.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Implementation of the individual plan if the person works directly with an individual.Identified Staff Members did not receive training on implementation of individual plans in training year 2022. While the staff read Individual Support Plan documentation and signed confirming they read the document, part of this training must be in-person with the individual present. 09/30/2023 Implemented
6400.165(c)Individual #1 is to receive Tresiba Flextouch Insulin to be administered in their thigh every morning. The administration is to alternate between the thighs, right and left. From 12/20/22 to 12/23/22, Individual #1 received their Insulin injection in their right thigh each morning.A prescription medication shall be administered as prescribed.MAR was updated to prompt staff members to use alternating thighs. 07/23/2023 Implemented
6400.167(a)(3)In December 2022, Individual #1 was prescribed Novolog. They were to receive 3 units at breakfast, unless their blood sugar was below 100. If their blood sugar level was below 100, they were to receive a half a dose totaling 1 ½ units. On 12/5/22 and 12/6/22, Individual #1's blood sugar tested at 84 and 96 respectively. Individual #1 was administered 2 units, as opposed to the correct dosage of 1 ½ units. In March 2023, Individual #1 was to receive 4 units at breakfast, unless their blood sugar was below 100. If blood sugar was below 100, Individual #1 was to receive half the dose. On 3/29/23, Individual #1's blood sugar tested at 100. They only received 3 units of Novolog that morning.Medication errors include the following: Administration of the wrong dose of medication.Individual #1 PCP order was changed to read 100 or below and 101 or higher. Our Medical Support Professional will be checking the MAR weekly to ensure the medication is administered correctly. 07/23/2023 Implemented
SIN-00207944 Renewal 07/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.15(c)The self-assessment completed on 12/21/21 identified 181a as a violation. There was no written summary of corrections for this violation.A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year. Director of Operations retrained all Associate Directors of Operations on the expectations surrounding the compliance of completing plan of corrections for self-assessments on 7/15/22. 07/15/2022 Implemented
SIN-00061182 Renewal 02/12/2014 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.46(i)The CPR was completed late for Staff #1. It was last completed on 2/17/12, but has not been completed within 2 years from this date. (i) Program specialists, direct service workers and drivers of and aides in vehicles shall be trained within 6 months after the day of initial employment and annually thereafter, by an individual certified as a trainer by a hospital or other recognized health care organization, in first aid, Heimlich techniques and cardio-pulmonary resuscitation. Resource Program Coordinator will issue a memo of retraining to all Team Members identified to be out of compliance with CPR Training within 6 months of hire date and/or within each subsequent 2 year time frame, outlining the requirements to remain within compliance. Associate Director of Residential Services will train Program Staff, including Supervisors, Coordinators and Specialists of the requirement to receive CPR Training within the required time frame. Team Members will not be scheduled to work with Individuals if the regulatory requirements are not satisfied. 04/30/2014 Implemented
SIN-00245355 Renewal 05/30/2024 Compliant - Finalized
SIN-00137745 Renewal 08/21/2018 Compliant - Finalized